Rebecca Stitt-Laugherty, Associate General Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/rebecca-stitt-laugherty/ Your modern revenue cycle solution Thu, 05 Jun 2025 18:01:10 +0000 en-US hourly 1 https://www.ensemblehp.com/wp-content/uploads/2023/10/Logo-Chevron-80x80.png Rebecca Stitt-Laugherty, Associate General Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/rebecca-stitt-laugherty/ 32 32 Diagnostic Monitoring Services Under Increased Federal Scrutiny Following $45M Settlement https://www.ensemblehp.com/blog/diagnostic-monitoring-services-under-increased-federal-scrutiny-following-45m-settlement/ Fri, 24 Feb 2023 15:08:06 +0000 https://www.ensemblehp.com/?p=10512 A cardiac monitoring company and its subsidiary agreed to a settlement with the DOJ following allegations they violated the False Claims Act. … Read More

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Summary

A cardiac monitoring company and its subsidiary agreed to a $44.9 million settlement with the Department of Justice (DOJ) following allegations they violated the False Claims Act (FCA) by billing federal programs for heart monitoring services that were knowingly performed outside the US. by unqualified technicians.

What Went Wrong?

In this recent example two cardiac monitoring companies, BioTelemetry and its subsidiary CardioNet, allegedly violated federal law prohibiting payment for services furnished outside the U.S. by knowingly billing for diagnostic services performed by a vendor in India.

BioTelemetry had an established workflow designed to route federal beneficiaries’ electrocardiogram (ECG) data to a U.S.-based independent diagnostic testing facility for analysis as required by federal programs, but when domestic workflows became backlogged, the ECG data was diverted to a contractor in India for analysis by technicians who didn’t meet U.S.-required qualifications.

Senior management was reportedly aware of the violation and began implementing technological controls that were ultimately insufficient to prevent unqualified India-based technicians from reviewing and analyzing ECG data for beneficiaries of federal programs.

As a result of the settlement, BioTelemetry entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services (HHS) Office of Inspector General which requires the implementation of a risk assessment and internal review process to identify and address evolving compliance risks. In addition, the CIA requires an annual independent to assess the medical necessity and appropriateness of claims billed to Medicare.

Key Takeaways

“With our law enforcement partners, our agency is extremely committed to investigating providers alleged of defying these requirements,” explained Special Agent in Charge Maureen R. Dixon of HHS. The government has made its position clear and the recent uptick in investigations demonstrates its continued emphasis on pursuing violations of federal programs.

Consider the following tips to avoid compliance risk and ensure your programs meet federal requirements:

    • Review remote diagnostic monitoring services provided by vendors to ensure patient data is managed and safeguarded in compliance with federal regulations.
    • Validate vendor credentials to prevent unqualified staff from interacting with patient data or performing services in violation of federal requirements.

    • Proactively audit workflows and data management protocols to ensure efficacy and prevent any perceptions of fraud or abuse.

As scrutiny across government healthcare programs increases, ensure your organization is taking the necessary steps to understand federal and state regulations and ensure compliance across internal and vendor-managed operations.

Rebecca Stitt-Laugherty has over 10 years of healthcare legal experience, specializing in health system operations, healthcare regulations and compliance. She currently serves as Associate General Counsel-Regulatory at Ensemble Health Partners, providing legal expertise and direction on healthcare regulatory and compliance matters.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> How to Mitigate Risks of Telehealth Fraud + Abuse https://www.ensemblehp.com/blog/eye-on-enforcement-how-to-mitigate-risks-of-telehealth-fraud-and-abuse/ Fri, 16 Sep 2022 17:43:21 +0000 https://www.ensemblehp.com/?p=8963 Providers should learn from recent convictions to reduce their risk of committing telehealth fraud and abuse as federal oversight continues. … Read More

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An Alert to Telemedicine Providers 

In response to numerous recent telehealth fraud and abuse investigations, the OIG issued a Special Fraud Alert warning practitioners to exercise caution around their arrangements with telemedicine companies. Telehealth fraud and abuse could result in both civil and criminal liability for providers under the Federal Anti-Kickback Statute and the False Claims Act, among other federal laws.  

Providers should learn from recent convictions to reduce their risk of committing telehealth fraud and abuse as federal oversight is expected to continue. 

Three Telehealth Fraud Convictions Cost Providers $20M

Below is a summary of three government investigations that resulted in the conviction, sentencing and the subsequent restitution totaling nearly $20 million from fraud and abuse. 

Investigation 1: Georgia Nurse Practitioner Convicted in Telemedicine Fraud Scheme Totaling Over $3 Million

A nurse practitioner (NP) facilitated orders for more than 3,000 orthotic braces generating over $3 million in fraudulent or excessive charges to Medicare. First, telemarketing companies captured the identities of senior citizens, identified through a telemarketing scheme, and bundled that information as “leads.” Next, the NP took the leads, signed her name to newly created fake patients’ medical records falsely claiming they provided examinations and then created orders for durable medical equipment (DME) such as orthotic braces for patients they never met or spoke with – including a knee brace for an amputee and a back brace for a recently deceased patient – in exchange for money. The NP’s fraudulent orders were then sold to DME companies that would generate reimbursement from Medicare. 

As a result of the investigation, the NP was convicted on charges of an illegal kickback conspiracy and five counts each of healthcare fraud, false statements related to healthcare and aggravated identity theft. The NP was sentenced to 87 months in federal prison and was ordered to pay more than $1.6 million in restitution for their role in the fraud scheme. 

Investigation 2: Ongoing Western District of Michigan Criminal and Civil Enforcement Action for Fraud Totaling Over $7 Million

Marketers called Medicare beneficiaries soliciting them for medically unnecessary braces and cancer genetic testing for screening purposes. The marketers then paid medical practitioners to purportedly review and sign these orders under the guise of telemedicine and sold those signed orders to the owners of the DME companies and genetic testing laboratories in violation of the Federal Anti-Kickback Statute. 

Through the ongoing investigation, dubbed Operation “Happy Clickers,” a series of criminal and civil enforcement actions were taken against the medical practitioners who signed off on the illegitimate orders resulting in $7.3 million of alleged Medicare fraud losses.  

One practitioner was sentenced to 21 months in federal prison followed by three years of supervised release and repayment of $5.7 million to Medicare. The other three practitioners entered into civil settlements agreeing to repay a total of $371,685 to resolve their liability. 

Investigation 3: Two Montana Nurse Practitioners Admit to Telehealth Scheme Totaling Over $9 Million

One Montana NP allegedly worked with certain staffing and telemedicine companies to receive money to sign unnecessary brace orders for Medicare beneficiaries regardless of medical necessity, often without ever talking to them. For the orders signed during this period, Medicare paid approximately $5.1 million and the NP was paid at least $124,900. 

Another Montana NP allegedly worked with certain staffing and telemedicine companies to receive money to sign brace orders that were prepared by telemarketers who had no medical training or certification. The NP routinely signed these orders for Medicare beneficiaries regardless of medical necessity. For the orders signed during this period, Medicare paid approximately $4.3 million and the NP was paid at least $94,395. 

As a result of the investigations, the two NPs were sentenced for conspiring to defraud Medicare of millions of dollars. The first NP was sentenced to nine months and ordered to pay more than $5 million in restitution. The second NP was sentenced to 12 months in federal prison and ordered to pay more than $4.3 million in restitution. Both will be placed on supervised release for three years after their release.  

Telehealth Fraud: Lessons Learned

Risk Areas:

  1. Up-coding: Do not inflate the time spent providing telemedicine services or the complexity of the services.   

  1. Misrepresenting the virtual service(s) provided: Understand the requirements for each type of telehealth interaction, which CPT codes apply, and how to bill for them. 

  1. Billing for services not rendered: Do not submit claims for services not provided, or not provided effectively (i.e., poor internet connection). 

  1. Kickbacks: Be aware of kickback scenarios. Recent examples include marketing tactics to make unsolicited contact with Medicare beneficiaries resulting in prescribing or referring them for unnecessary testing, prescriptions or DME for which the providers received kickbacks.  

Tips to Mitigate Risks: 

  1. Run comprehensive background and conflict checks on new employees and contractors to check for past illegal or unethical behavior. Hiring or contracting with someone who accepted kickbacks or is involved in inappropriate referral arrangements could bring Anti-Kickback Statute liability on an otherwise compliant company. 

  1. Provide regular training on providing telemedicine services as well as how to appropriately code and bill for those services. 

  1. Closely monitor charts and claims for patterns and outliers. If potential issues are spotted, evaluate whether the services and billing are appropriate. If issues are found, implement measures to prevent future occurrences. 

  1. Encourage and provide ways to report suspected noncompliant behavior. Conduct appropriate investigations into any allegations received. 

Taking proactive steps like the ones described above can help your organization ensure that its actions and behaviors will not be perceived as abuse or fraud. If you suspect fraud or abuse, contact the OIG; click here to learn more. 

Resources  

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